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�pUlry <br /> Z: ENVIRON ENTAL HEALTH tPARTMENT <br /> e'• :s T (� TAT AT �7 <br /> C'9(.hid'R�;P SAN ` OAQUI COUNTY Program Coordinators <br /> Donna K.Heran,R.E.H.S. Kase L. Coordinators <br /> Director 600 East Main Street, Stockton, California 95202 Y Y, <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Robert McClellon,R.E.H.S. <br /> Jeff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: ( / 1. Chemicals Hazards <br /> Address: ILIO mut tkd Carcinogens: <br /> Contact Person: ( S eCorrosives: <br /> Phone#: -3 6UPDusts: <br /> Proposed Date of investigation/inspection: / 1 ❑Explosives: <br /> PWammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR hivestigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> [14azardous Waste inspection ❑Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> _ ❑Detector Tubes(specify): <br /> 4. Type of Operation: , L ® ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO None(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety PhysiH1 Concerns:(v"all that apply&describe) Level of Protection: [IA [IB ❑C ®D <br /> 0 Heat or Cold Stress:�°F(high ambient temp.) <br /> ®Hard Hat <br /> Noise Sources: ®Safety Glasses/Goggles <br /> El Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> y <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ® veHearing protection <br /> Tvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> eavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biolo 'cal Hazards: <br /> [_I Snakes <br /> Insects bnodents El Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROV <br /> r <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: I ' <br /> e.g.,power lines,integrity of dikes,terrain,etc.): ff <br /> Plan Approved by: Date 4 <br />